Effects of preventive home visits on health-related quality-of-life and mortality in home-dwelling older adults.

OBJECTIVE: We explored the effectiveness of preventive home visits on the health-related quality-of-life (HRQoL) and mortality among independently community-dwelling older adults. DESIGN: A randomised controlled trial. SUBJECTS: Independently home-dwelling older adults 75 years and older, consisting of 211 in the intervention and 211 in the control group. SETTING: Hyvinkää town municipality, Finland. MAIN OUTCOME MEASURES: We used the change in HRQoL measured by the 15D scale as our primary outcome. Mortality at two years was retrieved from central registers. RESULTS: At the one-year time point, the HRQoL according to the 15D scores deteriorated in the control group, whereas we found no change in the intervention group. The difference between the 15D score changes between the groups was -0.015 (95% CI -0.029 to -0.0016; p = 0.028, adjusted for age, sex, and baseline value). At the two-year time point as the visits ended, that difference diminished. There was no difference in mortality between the groups during the 24-month follow-up. CONCLUSION: Preventive home visits implemented by a multidisciplinary team with CGA appear to help slow down the decline in HRQoL among older adults, although the effect diminishes when the visits end. Key points We are exploring preventive home visits as means to support the health-related quality-of-life (HRQoL) of home-dwelling older adults Multiprofessional preventive home visits in this intervention study helped to maintain the HRQoL when measured using 15D The effects on HRQoL diminished when the intervention ended, so could further benefits be attained with a longer intervention?The clinical trial registration number: ACTRN12616001411437.

The Effects of Preventive Home Visits on Older People's Use of Health Care and Social Services and Related Costs.

BACKGROUND: We use data from a randomized controlled trial on preventive home visits exploring effectiveness on health-related quality of life. In this article, we examine the intervention's cost-effectiveness and effects on quality-adjusted life years in older home-dwelling adults. METHODS: There were 422 independently home-dwelling participants in the randomized, controlled trial, all aged more than 75 years, with equal numbers in the control and intervention groups. The intervention took place in a municipality in Finland and consisted of multiprofessional preventive home visits. We gathered the data on health care and social services use from central registers and medical records during 1 year before the intervention and 2 years after the intervention. We analyzed the total health care and social services use and costs per person-years and the difference in change in health-related quality of life as measured using the 15D measure. We calculated quality-adjusted life years and incremental cost-effectiveness ratios. RESULTS: There was no significant difference in baseline use of services or in the total use and costs of health care and social services during the 2-year follow-up between the two groups. In the intervention group, health-related quality of life declined significantly more slowly compared with the control group (-0.015), but there was no significant difference in quality-adjusted life years gained between the groups. The cost-effectiveness plane showed 60% of incremental cost-effectiveness ratios lying in the dominant quadrant, representing additional effects with lower costs. CONCLUSIONS: This multiprofessional preventive home visit intervention appears to have positive effects on health-related quality of life without accruing additional costs. THE CLINICAL TRIAL REGISTRATION NUMBER: ACTRN12616001411437.

Differences in COPD-related readmissions to primary and secondary care hospitals.

OBJECTIVE: To study differences in readmissions to primary and secondary care hospitals for exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: A register-based study. SUBJECTS: The data were gathered from the hospital admissions register of the Finnish National Research and Development Centre for Welfare and Health. The data included all acute periods of treatment received by COPD patients aged over 44 years in 1996-2004 who had a principal or subsidiary diagnosis of COPD (ICD 10: J41-J44), respiratory infection (ICD 10: J00-J39, J85-J86) or cardiac insufficiency (ICD 10: I50), followed by an emergency readmission. Treatment had to have taken place in either a primary care hospital or a specialized ward for respiratory diseases or internal medicine in a secondary care hospital. MAIN OUTCOME MEASURES: The risk of readmission within a week of discharge, analysed by site of care. RESULTS: The risk of readmission within seven days of discharge is 1.74-fold for a patient treated in primary care compared with a patient treated in secondary care. CONCLUSIONS: COPD patients discharged from primary care hospitals have a greater risk of readmission, particularly within a week, than those discharged from secondary care. This risk may be attributed to differences in treatment procedures and arrangement of subsequent care. Thus, in the future, more attention should be paid to primary healthcare resources and staff training.

High hospital burden in overlap syndrome of asthma and COPD.

BACKGROUND: Overlap syndrome of asthma and chronic obstructive pulmonary disease (COPD) is a common condition, which is not well understood. This study describes the characteristics and hospital impact of patients suffering from this condition. METHODS: The data are comprised of the hospital discharge registry data maintained by National Institute for Health and Welfare [Terveyden ja hyvinvoinnin laitos (THL)] between 1972 and 2009 covering the entire Finnish population (5.35 million inhabitants in 2009). In THL, treatment periods for patients with the primary or secondary diagnosis of asthma or COPD were selected. From that data, patients over 34 years and their treatment periods starting and ending 2000-2009 with a principal or secondary diagnosis of asthma [International Classification of Diseases (ICD) 10: J45-J46] or COPD (ICD 10: J41-J44) were picked up. There were 105 122 such patients who had 343 420 treatment periods altogether. RESULTS: Patients with asthma were younger than patients with COPD and overlap syndrome, while COPD and overlap syndrome patients' age distribution was very similar. Patients with both asthma and COPD had 30.4% of all treatment periods, even though the percentage of all patients in this group was only 16.1%. These patients had an increased number of hospitalisation episodes across all age groups. Average number of treatment periods during 2000-2009 was 2.1 in asthma, 3.4 in COPD and 6.0 in overlap syndrome. Hospital impact of the same period in asthma was 939 900 days in COPD 1 517 308 and 1 000 724 days in overlap syndrome. CONCLUSION: Overlap syndrome of asthma and COPD is a common condition with high hospital impact for patients with this condition.

Does place of treatment affect prognosis for chronic obstructive pulmonary disease (COPD)?

BACKGROUND: It has been shown previously that mortality from acute chronic obstructive pulmonary disease (COPD) is higher at small hospitals than at large teaching hospitals. OBJECTIVE: To examine mortality at this acute stage and referral for further treatment by specialities in Finland, and trends in these between the 1990s and 2000s. METHODS: Data on all periods of treatment for patients over 44 years of age with a principal or subsidiary diagnosis of COPD beginning and ending in 1995-2004 were extracted from the Finnish hospital discharge register. Particular attention was paid to acute-stage treatment periods managed by a general practitioner, pulmonary specialist, or specialist in internal medicine that had begun as emergency admissions and had a principal diagnosis of COPD, and to any further treatment immediately following these. RESULTS: General practitioners referred 5.1% of their acute-stage patients to a specialist in secondary care in 1995-2004. Of the total of 77,445 acute-stage treatment periods, 3% (2328) ended in the death of the patient, implying the loss of 8.3% of the patients involved. The age- and sex-adjusted risk of death attached to treatment periods managed by a general practitioner relative to those managed by a pulmonary specialist was 0.83 (95% CI 0.75-0.91). CONCLUSION: It is quite possible to treat acute exacerbations of COPD efficiently and safely in a health centre hospital ward. New treatment modalities and health service structures seem to have led to a decrease in acute exacerbations of COPD since the year 2000, even though the number of patients with this disease has increased as a consequence of ageing of the population. Further research is required on the efficacy of treatment by a general practitioner, e.g., with data on re-hospitalization.

Is the treatment of acute COPD exacerbations in Finland shifting to general practitioners?

OBJECTIVE: To examine changes in the numbers of inpatient episodes and inpatient days and length of stay in acute exacerbations of COPD (chronic obstructive pulmonary disease) by specialization and by age group and sex distribution relative to the total population in the years 1995-2001. DESIGN: A register-based study. SUBJECTS: Data on inpatient episodes for patients aged 45 years or over with a principal diagnosis of COPD beginning in 1995-2001 and lasting less than 90 days were extracted from the hospital discharge register of the Finnish National Research and Development Centre for Welfare and Health. MAIN OUTCOME MEASURES: Numbers of inpatient episodes and days by age and sex in the specialties of general practice, pulmonary medicine, and internal medicine. RESULTS: The annual number of inpatient episodes increased by 10.9% from 1995 to 2001. The number of emergency treatment episodes supervised by a general practitioner increased by 36.8% during the same period and the number of such episodes supervised by a pulmonary specialist by 17.8%. The increase in age-adjusted emergency treatment episodes for men was 0.8% and that for women 18.5%. The average hospital stay shortened from 8.0 (SD 8.0) to 6.5 (SD 6.2) for men and from 8.7 (SD 8.5) to 7.3 (SD 6.8) for women. CONCLUSIONS: The greater increase in inpatient episodes for exacerbations of COPD in relation to the total population among women than among men may be attributed to differences in smoking habits and ageing between the sexes. Responsibility for COPD cases is clearly shifting to general practitioners. This is due partly to the national programme for the treatment of obstructive pulmonary diseases and the associated in-service training provided for general practitioners and partly to financial reasons. More detailed investigations should be made into the quality of the treatment.